Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE Member Management Requirements - MMIS A B C D EBE1.02.03BE1.03BE1.04BE1.05BE1.06BE1.07a. Member name and member number.b. Provider name and provider number.c. TCN and denial notice number.d. Date of service and date of NOD.e. Exception code.f. Written reason for denial.g. Same format as current ambulance NOD.Provide the capability to generate NODs for denials of selected servicessuch as therapy services, rehabilitation therapy service, claims foroccupational therapy, physical therapy and speech therapy.Support management of member information, including archives,reports, transaction and transaction error tracking.Generate notification when member information is received from externalsources to update member records.Receive and process member eligibility information from externalsources such as, IME‟s Integrated Eligibility System or Social SecurityAdministration (SSA‟s) state data exchange, for a given period of time;produce total and detail information that supports error correction andsynchronization. Apply reconciliation changes to master file. Produce afile of changed records to be sent to originating source.Archive member data sets and update transactions according to IMEprovided parameters.Provide member data to support case identification, tracking andreporting for the EPSDT services covered under Medicaid.Yes No SM 80YesYesYesYesYes No SM 100Yes No SM 120BE1.07.01 Provide the capability to meet the business requirements of EPSDT. Yes No SM 150BE1.07.02BE1.07.03BE1.07.04BE1.07.05Provide the capability to track screenings, referrals and treatments forEPSDT members.Identify all members eligible for EPSDT services within the benefit planadministration rules engine.Provide the capability for recording all case activity including, but notlimited to:a. Logs of notices.b. Recommended dates of service from the periodicity table.c. Actual dates of services.d. IME and contractor contacts.e. Case notes.Use the workflow management process to provide and log notices, trackservices provided and enter case notes for each eligible member in aprogram (such as EPSDT) and at a minimum, include processes listedbelow:a. Automatically generate notification letters or electroniccommunications, according to specifications set by IME. Identify thefamily head of household or foster care worker and generate screeningsletters and or electronic communications to this individual, even if thechild resides at a different address.b. Retrieve data from the MMIS claims and encounter data (if applicable)to compare to services recommended from the periodicity table.c. Provide for the inclusion of claims attachments.d. Automatically compare and report claims to the periodicity table, todetermine if the member received the health checkup examination andrelated services at the recommended intervals.YesYesYesYesYesYesYesYesYes No SM 80Section 9.1.1.1.2,Requirement #BE1.02.03Section 9.1.1.1.2,Requirement #BE1.03Section 9.1.1.1.2,Requirement #BE1.04Section 9.1.1.1.2,Requirement #BE1.05Section 9.1.1.1.2,Requirement #BE1.06Section 9.1.1.1.2,Requirement #BE1.07Section 9.1.1.1.2,Requirement #BE1.07.01Section 9.1.1.1.2,Requirement #BE1.07.02Section 9.1.1.1.2,Requirement #BE1.07.03Section 9.1.1.1.2,Requirement #BE1.07.04Section 9.1.1.1.2,Requirement #BE1.07.059.1.1.1 | 2